In a supplement to its inaugural issue, the Journal of Hospital Medicine published core competencies for hospitalists covering 3 areas: clinical conditions, systems in health care, and procedures.1 Completion of a traditional internal medicine residency may not provide hospitalists with the skills necessary to safely perform necessary procedures such as thoracentesis. A recent article reported that most internal medicine residents surveyed were uncomfortable performing common procedures, and their discomfort was higher for thoracentesis than for central line insertion, lumbar puncture, or paracentesis.2 This confirmed a previous report that family practice residents had low confidence in performing thoracenteses.3 Thoracentesis also carries the risk of the potentially life‐threatening complication of pneumothorax, which may be increased when performed by physicians‐in‐training.4

One method for improving training and assessment is the use of simulation technology. Simulation has been used to increase knowledge, provide opportunities for deliberate and safe practice, and shape the development of clinical skills.5, 6 Simulation has also been advocated for assessing competence in procedures including carotid angiography,7 emergency airway management,8 basic bronchoscopy,9 and advanced cardiac life support (ACLS).10, 11

Recently, we used simulation technology to help residents reach mastery learning standards for ACLS.11 Mastery learning,12 an extreme form of competency‐based education,13 implies that learners have acquired the clinical knowledge and skill measured against rigorous achievement standards. In mastery learning, educational results are equivalent, whereas educational practice time differs. To demonstrate mastery learning, we first documented a 38% improvement in skill after a simulation‐based educational intervention10 and used a multidisciplinary panel to determine mastery achievement standards for ACLS skills in 6 clinical scenarios.14 These standards were used in a study in which the amount of time needed to achieve skill mastery was allowed to vary while the skill outcomes of the residents were identical clinically.11

The present study had 4 aims. The first was to assess the baseline skill and knowledge of third‐year residents in thoracentesis. The second was to compare the thoracentesis‐related knowledge and skills of residents before and after an educational intervention. The third was to assess the correlation of medical knowledge and clinical experience with performance on a clinical skills examination after simulation training. The last was to document the feasibility of incorporating simulation‐based education into a training program.

METHODS

RESULTS

All residents consented to participate and completed the entire training protocol. Table 1 presents demographic data about the residents. Most had limited experience performing and supervising thoracenteses.

Interrater reliability for the thoracentesis checklist data was calculated at pretest. Across the 25 checklist items, the mean kappa coefficient was very high (_n = .94). The MPS used as the mastery achievement standard was 80% (eg, 20 of 25 checklist items). This was the mean of the Angoff and Hofstee ratings obtained from the first judgment of the expert panel and is displayed in Figure 1.

Figure 1

No resident achieved mastery at pretest. However, 37 of the 40 medicine residents (93%) achieved mastery within the standard 4‐hour thoracentesis curriculum. The remaining 3 residents (7%) needed extra time ranging from 20 to 90 minutes to reach mastery.

Figure 1 is a graphic portrait with descriptive statistics of the residents' pretest and posttest performance on the thoracentesis written and clinical skills exams. For the written exam, the mean score rose from 57.63% to 89.75%, a statistically significant improvement of 56% from pretest to posttest (t_[39] = 17.0, P < .0001). The clinical skills exam also showed a highly significant 71% pretest‐to‐posttest gain, as the mean score rose from 51.70% to 88.3% (t_[39] = 15.6, P < .0001).

Results from the regression analysis indicate that neither pretest performance, medical knowledge measured by local or USMLE examinations, nor thoracentesis clinical experience was correlated with the posttest measure of thoracentesis clinical skills. However, the need for additional practice to reach the mastery standard on the posttest was a powerful negative predictor of posttest performance: b = .27 (95% CI = .46 to .09; P < .006; r² = .28). For those residents who required extra practice time, the initial clinical skills posttest score was 20% lower than that of their peers. Although the need for extra deliberate practice was associated with relatively lower initial posttest scores, all residents ultimately met or exceeded the rigorous thoracentesis MPS.

The responses of the 40 residents on a course evaluation questionnaire were uniformly positive. Responses were recorded on a Likert scale where 1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, and 5 = strongly agree (Table 2). The data show that residents strongly agreed that practice with the medical simulator boosts clinical skills and self‐confidence, that they received useful feedback from the training sessions, and that deliberate practice using the simulator is a valuable educational experience. Residents were uncertain whether practice with the medical simulator has more educational value than patient care.

DISCUSSION

This study demonstrates the use of a mastery learning model to develop the thoracentesis skills of internal medicine residents to a high level. Use of a thoracentesis model in a structured educational program offering an opportunity for deliberate practice with feedback produced large and consistent improvements in residents' skills. An important finding of our study is that despite having completed most of their internal medicine training, residents displayed poor knowledge and clinical skill in thoracentesis procedures at baseline. This is similar to previous studies showing that the procedural skills and knowledge of physicians at all stages of training are often poor. Examples of areas in which significant gaps were found include basic skills such as chest radiography,27 emergency airway management,8 and pulmonary auscultation.28 In contrast, after the mastery learning program, all the residents met or exceeded the MPS for the thoracentesis clinical procedure and scored much higher on the posttest written examination.

Our data also demonstrate that medical knowledge measured by procedure‐specific pretests and posttests and USMLE Steps 1 and 2 scores were not correlated with thoracentesis skill acquisition. This reinforces findings from our previous studies of ACLS skill acquisition10, 11 and supports the difference between professional and academic achievement. Pretest skill performance and clinical experience also were not correlated with posttest outcomes. However, the amount of deliberate practice needed to reach the mastery standard was a powerful negative predictor of posttest thoracentesis skill scores, replicating our research on ACLS.11 We believe that clinical experience was not correlated with posttest outcomes because residents infrequently performed thoracenteses procedures during their training.

This project demonstrates a practical model for outcomes‐based education, certification, and program accreditation. Given the need to move procedural training in internal medicine beyond such historical methods as see one, do one, teach one,29 extension of the mastery model to other invasive procedures deserves further study. At our institution we have been encouraged by the ability of simulation‐based education in ACLS to promote long‐term skill retention30 and improvement in the quality of actual patient care.31 In addition to studying these outcomes for thoracentesis, we plan to incorporate the use of ultrasound when training residents to perform procedures such as thoracentesis and central venous catheter insertion.

Given concerns about the quality of resident preparation to perform invasive procedures, programs such as this should be considered as part of the procedural certification process. As shown by our experience with several classes of residents (n = 158), use of simulation technology to reach high procedural skill levels is effective and feasible in internal medicine residency training. In addition, our residents have consistently enjoyed participating in the simulated training programs. Postcourse questionnaires show that residents agree that deliberate practice with simulation technology complements but does not replace patient care in graduate medical education.5, 10

An important question needing more research is whether performance in a simulated environment transfers to actual clinical settings. Several small studies have demonstrated such a relationship,8, 9, 31, 32 yet the transfer of simulated training to clinical practice requires further study. More work should also be done to assess long‐term retention of skills30 and to determine the utility and benefit of simulation‐based training in procedural certification and credentialing.

This study had several limitations. It was conducted in 1 training program at a single medical center. The sample size (n = 40) was relatively small. The thoracentesis model was used for both education and testing, potentially confounding the events. However, these limitations do not diminish the pronounced impact that the simulation‐based training had on the skills and knowledge of our residents.

In conclusion, this study has demonstrated the ability of deliberate practice using a thoracentesis model to produce high‐level performance of simulated thoracenteses. The project received high ratings from learners and provides reliable assessments of procedural competence. Although internists are performing fewer invasive procedures now than in years past, procedural training is still an important component of internal medicine training.29, 33 Attainment of high procedural skill levels may be especially important for residents who plan to practice hospital medicine. We believe that simulation‐based training using deliberate practice should be a key contributor to future internal medicine residency education, certification, and accreditation.

In a supplement to its inaugural issue, the Journal of Hospital Medicine published core competencies for hospitalists covering 3 areas: clinical conditions, systems in health care, and procedures.1 Completion of a traditional internal medicine residency may not provide hospitalists with the skills necessary to safely perform necessary procedures such as thoracentesis. A recent article reported that most internal medicine residents surveyed were uncomfortable performing common procedures, and their discomfort was higher for thoracentesis than for central line insertion, lumbar puncture, or paracentesis.2 This confirmed a previous report that family practice residents had low confidence in performing thoracenteses.3 Thoracentesis also carries the risk of the potentially life‐threatening complication of pneumothorax, which may be increased when performed by physicians‐in‐training.4

One method for improving training and assessment is the use of simulation technology. Simulation has been used to increase knowledge, provide opportunities for deliberate and safe practice, and shape the development of clinical skills.5, 6 Simulation has also been advocated for assessing competence in procedures including carotid angiography,7 emergency airway management,8 basic bronchoscopy,9 and advanced cardiac life support (ACLS).10, 11

Recently, we used simulation technology to help residents reach mastery learning standards for ACLS.11 Mastery learning,12 an extreme form of competency‐based education,13 implies that learners have acquired the clinical knowledge and skill measured against rigorous achievement standards. In mastery learning, educational results are equivalent, whereas educational practice time differs. To demonstrate mastery learning, we first documented a 38% improvement in skill after a simulation‐based educational intervention10 and used a multidisciplinary panel to determine mastery achievement standards for ACLS skills in 6 clinical scenarios.14 These standards were used in a study in which the amount of time needed to achieve skill mastery was allowed to vary while the skill outcomes of the residents were identical clinically.11

The present study had 4 aims. The first was to assess the baseline skill and knowledge of third‐year residents in thoracentesis. The second was to compare the thoracentesis‐related knowledge and skills of residents before and after an educational intervention. The third was to assess the correlation of medical knowledge and clinical experience with performance on a clinical skills examination after simulation training. The last was to document the feasibility of incorporating simulation‐based education into a training program.

METHODS

RESULTS

All residents consented to participate and completed the entire training protocol. Table 1 presents demographic data about the residents. Most had limited experience performing and supervising thoracenteses.

Interrater reliability for the thoracentesis checklist data was calculated at pretest. Across the 25 checklist items, the mean kappa coefficient was very high (_n = .94). The MPS used as the mastery achievement standard was 80% (eg, 20 of 25 checklist items). This was the mean of the Angoff and Hofstee ratings obtained from the first judgment of the expert panel and is displayed in Figure 1.

Figure 1

No resident achieved mastery at pretest. However, 37 of the 40 medicine residents (93%) achieved mastery within the standard 4‐hour thoracentesis curriculum. The remaining 3 residents (7%) needed extra time ranging from 20 to 90 minutes to reach mastery.

Figure 1 is a graphic portrait with descriptive statistics of the residents' pretest and posttest performance on the thoracentesis written and clinical skills exams. For the written exam, the mean score rose from 57.63% to 89.75%, a statistically significant improvement of 56% from pretest to posttest (t_[39] = 17.0, P < .0001). The clinical skills exam also showed a highly significant 71% pretest‐to‐posttest gain, as the mean score rose from 51.70% to 88.3% (t_[39] = 15.6, P < .0001).

Results from the regression analysis indicate that neither pretest performance, medical knowledge measured by local or USMLE examinations, nor thoracentesis clinical experience was correlated with the posttest measure of thoracentesis clinical skills. However, the need for additional practice to reach the mastery standard on the posttest was a powerful negative predictor of posttest performance: b = .27 (95% CI = .46 to .09; P < .006; r² = .28). For those residents who required extra practice time, the initial clinical skills posttest score was 20% lower than that of their peers. Although the need for extra deliberate practice was associated with relatively lower initial posttest scores, all residents ultimately met or exceeded the rigorous thoracentesis MPS.

The responses of the 40 residents on a course evaluation questionnaire were uniformly positive. Responses were recorded on a Likert scale where 1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, and 5 = strongly agree (Table 2). The data show that residents strongly agreed that practice with the medical simulator boosts clinical skills and self‐confidence, that they received useful feedback from the training sessions, and that deliberate practice using the simulator is a valuable educational experience. Residents were uncertain whether practice with the medical simulator has more educational value than patient care.

DISCUSSION

This study demonstrates the use of a mastery learning model to develop the thoracentesis skills of internal medicine residents to a high level. Use of a thoracentesis model in a structured educational program offering an opportunity for deliberate practice with feedback produced large and consistent improvements in residents' skills. An important finding of our study is that despite having completed most of their internal medicine training, residents displayed poor knowledge and clinical skill in thoracentesis procedures at baseline. This is similar to previous studies showing that the procedural skills and knowledge of physicians at all stages of training are often poor. Examples of areas in which significant gaps were found include basic skills such as chest radiography,27 emergency airway management,8 and pulmonary auscultation.28 In contrast, after the mastery learning program, all the residents met or exceeded the MPS for the thoracentesis clinical procedure and scored much higher on the posttest written examination.

Our data also demonstrate that medical knowledge measured by procedure‐specific pretests and posttests and USMLE Steps 1 and 2 scores were not correlated with thoracentesis skill acquisition. This reinforces findings from our previous studies of ACLS skill acquisition10, 11 and supports the difference between professional and academic achievement. Pretest skill performance and clinical experience also were not correlated with posttest outcomes. However, the amount of deliberate practice needed to reach the mastery standard was a powerful negative predictor of posttest thoracentesis skill scores, replicating our research on ACLS.11 We believe that clinical experience was not correlated with posttest outcomes because residents infrequently performed thoracenteses procedures during their training.

This project demonstrates a practical model for outcomes‐based education, certification, and program accreditation. Given the need to move procedural training in internal medicine beyond such historical methods as see one, do one, teach one,29 extension of the mastery model to other invasive procedures deserves further study. At our institution we have been encouraged by the ability of simulation‐based education in ACLS to promote long‐term skill retention30 and improvement in the quality of actual patient care.31 In addition to studying these outcomes for thoracentesis, we plan to incorporate the use of ultrasound when training residents to perform procedures such as thoracentesis and central venous catheter insertion.

Given concerns about the quality of resident preparation to perform invasive procedures, programs such as this should be considered as part of the procedural certification process. As shown by our experience with several classes of residents (n = 158), use of simulation technology to reach high procedural skill levels is effective and feasible in internal medicine residency training. In addition, our residents have consistently enjoyed participating in the simulated training programs. Postcourse questionnaires show that residents agree that deliberate practice with simulation technology complements but does not replace patient care in graduate medical education.5, 10

An important question needing more research is whether performance in a simulated environment transfers to actual clinical settings. Several small studies have demonstrated such a relationship,8, 9, 31, 32 yet the transfer of simulated training to clinical practice requires further study. More work should also be done to assess long‐term retention of skills30 and to determine the utility and benefit of simulation‐based training in procedural certification and credentialing.

This study had several limitations. It was conducted in 1 training program at a single medical center. The sample size (n = 40) was relatively small. The thoracentesis model was used for both education and testing, potentially confounding the events. However, these limitations do not diminish the pronounced impact that the simulation‐based training had on the skills and knowledge of our residents.

In conclusion, this study has demonstrated the ability of deliberate practice using a thoracentesis model to produce high‐level performance of simulated thoracenteses. The project received high ratings from learners and provides reliable assessments of procedural competence. Although internists are performing fewer invasive procedures now than in years past, procedural training is still an important component of internal medicine training.29, 33 Attainment of high procedural skill levels may be especially important for residents who plan to practice hospital medicine. We believe that simulation‐based training using deliberate practice should be a key contributor to future internal medicine residency education, certification, and accreditation.

In a supplement to its inaugural issue, the Journal of Hospital Medicine published core competencies for hospitalists covering 3 areas: clinical conditions, systems in health care, and procedures.1 Completion of a traditional internal medicine residency may not provide hospitalists with the skills necessary to safely perform necessary procedures such as thoracentesis. A recent article reported that most internal medicine residents surveyed were uncomfortable performing common procedures, and their discomfort was higher for thoracentesis than for central line insertion, lumbar puncture, or paracentesis.2 This confirmed a previous report that family practice residents had low confidence in performing thoracenteses.3 Thoracentesis also carries the risk of the potentially life‐threatening complication of pneumothorax, which may be increased when performed by physicians‐in‐training.4

One method for improving training and assessment is the use of simulation technology. Simulation has been used to increase knowledge, provide opportunities for deliberate and safe practice, and shape the development of clinical skills.5, 6 Simulation has also been advocated for assessing competence in procedures including carotid angiography,7 emergency airway management,8 basic bronchoscopy,9 and advanced cardiac life support (ACLS).10, 11

Recently, we used simulation technology to help residents reach mastery learning standards for ACLS.11 Mastery learning,12 an extreme form of competency‐based education,13 implies that learners have acquired the clinical knowledge and skill measured against rigorous achievement standards. In mastery learning, educational results are equivalent, whereas educational practice time differs. To demonstrate mastery learning, we first documented a 38% improvement in skill after a simulation‐based educational intervention10 and used a multidisciplinary panel to determine mastery achievement standards for ACLS skills in 6 clinical scenarios.14 These standards were used in a study in which the amount of time needed to achieve skill mastery was allowed to vary while the skill outcomes of the residents were identical clinically.11

The present study had 4 aims. The first was to assess the baseline skill and knowledge of third‐year residents in thoracentesis. The second was to compare the thoracentesis‐related knowledge and skills of residents before and after an educational intervention. The third was to assess the correlation of medical knowledge and clinical experience with performance on a clinical skills examination after simulation training. The last was to document the feasibility of incorporating simulation‐based education into a training program.

METHODS

RESULTS

All residents consented to participate and completed the entire training protocol. Table 1 presents demographic data about the residents. Most had limited experience performing and supervising thoracenteses.

Interrater reliability for the thoracentesis checklist data was calculated at pretest. Across the 25 checklist items, the mean kappa coefficient was very high (_n = .94). The MPS used as the mastery achievement standard was 80% (eg, 20 of 25 checklist items). This was the mean of the Angoff and Hofstee ratings obtained from the first judgment of the expert panel and is displayed in Figure 1.

Figure 1

No resident achieved mastery at pretest. However, 37 of the 40 medicine residents (93%) achieved mastery within the standard 4‐hour thoracentesis curriculum. The remaining 3 residents (7%) needed extra time ranging from 20 to 90 minutes to reach mastery.

Figure 1 is a graphic portrait with descriptive statistics of the residents' pretest and posttest performance on the thoracentesis written and clinical skills exams. For the written exam, the mean score rose from 57.63% to 89.75%, a statistically significant improvement of 56% from pretest to posttest (t_[39] = 17.0, P < .0001). The clinical skills exam also showed a highly significant 71% pretest‐to‐posttest gain, as the mean score rose from 51.70% to 88.3% (t_[39] = 15.6, P < .0001).

Results from the regression analysis indicate that neither pretest performance, medical knowledge measured by local or USMLE examinations, nor thoracentesis clinical experience was correlated with the posttest measure of thoracentesis clinical skills. However, the need for additional practice to reach the mastery standard on the posttest was a powerful negative predictor of posttest performance: b = .27 (95% CI = .46 to .09; P < .006; r² = .28). For those residents who required extra practice time, the initial clinical skills posttest score was 20% lower than that of their peers. Although the need for extra deliberate practice was associated with relatively lower initial posttest scores, all residents ultimately met or exceeded the rigorous thoracentesis MPS.

The responses of the 40 residents on a course evaluation questionnaire were uniformly positive. Responses were recorded on a Likert scale where 1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, and 5 = strongly agree (Table 2). The data show that residents strongly agreed that practice with the medical simulator boosts clinical skills and self‐confidence, that they received useful feedback from the training sessions, and that deliberate practice using the simulator is a valuable educational experience. Residents were uncertain whether practice with the medical simulator has more educational value than patient care.

DISCUSSION

This study demonstrates the use of a mastery learning model to develop the thoracentesis skills of internal medicine residents to a high level. Use of a thoracentesis model in a structured educational program offering an opportunity for deliberate practice with feedback produced large and consistent improvements in residents' skills. An important finding of our study is that despite having completed most of their internal medicine training, residents displayed poor knowledge and clinical skill in thoracentesis procedures at baseline. This is similar to previous studies showing that the procedural skills and knowledge of physicians at all stages of training are often poor. Examples of areas in which significant gaps were found include basic skills such as chest radiography,27 emergency airway management,8 and pulmonary auscultation.28 In contrast, after the mastery learning program, all the residents met or exceeded the MPS for the thoracentesis clinical procedure and scored much higher on the posttest written examination.

Our data also demonstrate that medical knowledge measured by procedure‐specific pretests and posttests and USMLE Steps 1 and 2 scores were not correlated with thoracentesis skill acquisition. This reinforces findings from our previous studies of ACLS skill acquisition10, 11 and supports the difference between professional and academic achievement. Pretest skill performance and clinical experience also were not correlated with posttest outcomes. However, the amount of deliberate practice needed to reach the mastery standard was a powerful negative predictor of posttest thoracentesis skill scores, replicating our research on ACLS.11 We believe that clinical experience was not correlated with posttest outcomes because residents infrequently performed thoracenteses procedures during their training.

This project demonstrates a practical model for outcomes‐based education, certification, and program accreditation. Given the need to move procedural training in internal medicine beyond such historical methods as see one, do one, teach one,29 extension of the mastery model to other invasive procedures deserves further study. At our institution we have been encouraged by the ability of simulation‐based education in ACLS to promote long‐term skill retention30 and improvement in the quality of actual patient care.31 In addition to studying these outcomes for thoracentesis, we plan to incorporate the use of ultrasound when training residents to perform procedures such as thoracentesis and central venous catheter insertion.

Given concerns about the quality of resident preparation to perform invasive procedures, programs such as this should be considered as part of the procedural certification process. As shown by our experience with several classes of residents (n = 158), use of simulation technology to reach high procedural skill levels is effective and feasible in internal medicine residency training. In addition, our residents have consistently enjoyed participating in the simulated training programs. Postcourse questionnaires show that residents agree that deliberate practice with simulation technology complements but does not replace patient care in graduate medical education.5, 10

An important question needing more research is whether performance in a simulated environment transfers to actual clinical settings. Several small studies have demonstrated such a relationship,8, 9, 31, 32 yet the transfer of simulated training to clinical practice requires further study. More work should also be done to assess long‐term retention of skills30 and to determine the utility and benefit of simulation‐based training in procedural certification and credentialing.

This study had several limitations. It was conducted in 1 training program at a single medical center. The sample size (n = 40) was relatively small. The thoracentesis model was used for both education and testing, potentially confounding the events. However, these limitations do not diminish the pronounced impact that the simulation‐based training had on the skills and knowledge of our residents.

In conclusion, this study has demonstrated the ability of deliberate practice using a thoracentesis model to produce high‐level performance of simulated thoracenteses. The project received high ratings from learners and provides reliable assessments of procedural competence. Although internists are performing fewer invasive procedures now than in years past, procedural training is still an important component of internal medicine training.29, 33 Attainment of high procedural skill levels may be especially important for residents who plan to practice hospital medicine. We believe that simulation‐based training using deliberate practice should be a key contributor to future internal medicine residency education, certification, and accreditation.

The increasing burden of chronic illness has prompted concerns about the traditional education model that focuses on management of acute disease.13 Chronic illness has replaced acute disease as the major cause of disability and total national health care expenditures.46 Medical educators have called for improved chronic disease curricula,2, 3 and the Institute of Medicine has asserted that health professions, including medicine and pharmacy, must reexamine how students are educated to manage patients with complex illnesses.7, 8 Despite the rising prevalence of chronic illness, the positive attitudes of medical students toward providing care to such patients decline during training.2, 9 One theory is that the current model of core clerkship training excessively exposes students to highly complex, seriously ill hospitalized patients. Students may become disillusioned and overwhelmed by these encounters, particularly without the opportunity to see improvement or thriving in the outpatient setting.2

There are few curricula on how to transition chronically ill patients from an inpatient to an outpatient setting and the inherent safety risks of this transition. For these patients, the posthospital discharge period is particularly confusing because of the sudden change in health status and new medication regimens.1012 It is very likely that communication among providers and patients will be insufficient during the discharge process,11, 1315 yet physicians tend to overestimate patients' understanding of postdischarge treatment plans and thereby underanticipate problems.16 One intervention to address these concerns is a postdischarge visit. Home visits have been shown to improve students' understanding of continuity of care and of the impact of chronic illness on their patients' medical and psychosocial situations.1719

There is scant structured teaching of third‐year medical students about another critical aspect of transitional care: the role of different health care disciplines. Although research about the impact of undergraduate interdisciplinary education on patient outcomes is limited, training students in interdisciplinary collaboration may improve their ability to provide quality care.2022 Multiple disciplines are critical for a smooth transition of chronically ill patients from an inpatient to an outpatient setting. In particular, pharmacist involvement in a predischarge medication review, patient counseling, and telephone follow‐up has been associated with improved outcomes.11, 12, 23, 24 Early introduction of interdisciplinary team training can improve student attitudes about working within a team.25

To teach the importance of safe discharges and interdisciplinary collaboration in caring for chronically ill patients, we developed an inpatient medicine clerkship curriculum for medical and pharmacy students that included postdischarge visits to students' own team patients. The purpose of the study was to assess the impact of this didactic and experiential curriculum on students' attitudes and self‐assessed skills in the interdisciplinary care and transitional care of chronically ill patients. We hypothesized that the discharge curriculum would improve student attitudes and self‐assessed skills in these domains. Finally, we hypothesized that visiting a patient's home would highlight for students the potential challenges of care transitions for patients.

METHODS

Intervention (Curriculum Description)

We developed a 3‐part pilot interdisciplinary curriculum (Fig. 1). During the first 2 weeks of the IM clerkship, interdisciplinary faculty, including 3 pharmacists, 2 hospitalists, and occasionally a social worker and geriatric clinical nurse specialist, led a 1‐hour interactive workshop on transitional care. The 3 workshop topics were: roles that various disciplines such as social work and pharmacy play in discharge care; the challenges a patient faces around the time of discharge, using a typical case; and discussion of elements of a postdischarge visit.

Figure 1

Medical and pharmacy students were partnered based on clerkship team assignments in teams of up to 3 student partners (1 or 2 medical students and 1 pharmacy student). Partners were advised to select a consenting patient known to them from the ward team for 1 postdischarge visit. Suggested selection criteria were at least 1 chronic illness, 1 prior hospitalization, and older than age 65 because patients fitting these criteria are most at risk for readmission or adverse outcomes following discharge.15, 26, 27 The student partners scheduled a postdischarge visit by the end of the rotation to the patient's home, nursing home, or subacute care facility. Each patient and the patient's primary care provider (PCP) gave informed consent.

During the postdischarge visit, student partners assessed medication discrepancies, environmental safety, and clinical status using structured data collection protocols developed by the investigators after review of the literature.28, 29 After the visit, students reported back to the ward teams on the patient's status and wrote a visit summary letter to the patient's PCP. The letter described the patient's clinical status and home environment, any medication discrepancies, and follow‐up plans and included a reflection piece. Reflection questions included, How did the visit change your perspective of patient discharge? What were the most critical aspects of this or any discharge? How do you think this experience will affect your future practice? What was the best thing about this experience?

During the last 2 weeks of the rotation, all student participants met with faculty preceptors for an hour‐long group debriefing session on the postdischarge visits.

RESULTS

DISCUSSION

A discharge curriculum that included a postdischarge visit to a recently hospitalized patient improved the attitudes and self‐assessed skills of third‐year medical students and fourth‐year pharmacy students about interdisciplinary collaboration and transitions in care. It also deepened their appreciation of the impact of chronic illness on individual patients. To our knowledge, this is the first study to report an interdisciplinary curriculum with postdischarge home visits for students on their inpatient medicine clerkship.

Our curriculum was unique because its activities were linked to patients the students had cared for in the inpatient setting, a relationship that was key to students accepting the curriculum, as was the autonomy they had in selecting one of their patients for a visit. Although home visits are often part of medical school training, they generally occur in the preclinical years5, 19 or during third‐year primary care rotations, during which students are assigned patients at home or in outpatient facilities.17, 32 Home visits have been qualitatively reported to be a valuable aspect of geriatric, primary care, and other ambulatory‐based rotations of medical students.17, 19, 32 Postdischarge visits in graduate medical education have been shown to improve residents' awareness of and skills with transitions in care.28, 33, 34

Another novel aspect of this curriculum was the interdisciplinary collaboration in discharge planning and postdischarge visits. Although educators have implemented conferences on interdisciplinary education in preclinical medical education,3537 patient‐centered curricula in real‐time allow realistic interdisciplinary collaboration between medical and pharmacy students in their core clerkships. In our study, quantitative and qualitative data showed that the student partners valued each other's expertise in the context of a clinically relevant activitydischarge planning and a follow‐up home visit. Students reported confidence in their collaborative abilities after completing the curriculum, and comments supported a broadened understanding of other professionals' roles in patient care. Given that pharmacist involvement in discharge planning has been shown to improve patient outcomes,11, 24 our study supports the idea that medical educators should develop structured curricula on interdisciplinary training in core clerkships.

By evaluating the impact of hospitalization and chronic illness on their patients after discharge, our students developed an appreciation for safe transitions and opportunities to improve patients' health and level of function. We observed that students also appreciated the positive effect of the home environment on patient health and well‐being. From their postdischarge visit, students also became aware of the need for communication with primary care providers, particularly for patients with comorbidities. This type of transitional care experience may help to counter the negative attitudes toward chronic illness that students typically develop during clerkships.2, 9, 38, 39

Of note, although pharmacy students reported improvement in their attitudes and skills with transitional care, the trend toward significance was less than that for medical students. This difference was consistent with the broader rotation goals of each group. At the end of the curriculum, the pharmacy students expressed more comfort with medication review than did medical students, although the latter were better able to conduct transitional care including postdischarge visits and identification of barriers or facilitators to a safe discharge. Another interesting note is that pharmacy students came into the curriculum with a better understanding of the roles of physicians, whereas the medical students had a less clear idea of the pharmacist's role. A possible explanation is that pharmacy students are better trained in their preclinical years to work as a team with medical personnel. The pharmacy school curriculum places an emphasis on independent learning and interdisciplinary collaboration, which may lead to the greater comfort felt by the pharmacy students.

This study had several limitations. The absolute number of visits was small overall; however, nearly all student partners completed their visits. Although the response rate to the postcurriculum survey was high, the response rate to matched prepost surveys was lower. In addition, the survey questions were not validated. Further, although there was significant improvement in students' attitudes and self‐assessed skills after completion of the curriculum, we cannot be certain whether this improvement was a result of the curriculum or of other rotation experiences. We attempted to clarify this effect by asking if the curriculum added to their learning beyond other clerkship experiences, and students perceived that our curriculum was responsible for the positive effect. Also, the curriculum was used at 1 academic site and may not be generalizable to other hospitals, student populations, or team structures. The patients were selected by students, and thus the results may not be reproducible for every population; in some situations, students had to ask several patients until a patient consented to a postdischarge visit.

In implementing this interdisciplinary curriculum, we were challenged by the discordant schedules of the medical and pharmacy students. Initially, it was also difficult to overcome students' concerns about adding an additional expectation to an already busy rotation. The medical students, in particular, voiced concerns about having to leave the hospital during their inpatient rotation. However, this has become much less of an issue with time as the value of the postdischarge visit has become clear to students and team members, with the latter now aware of and supportive of the program.

This discharge curriculum represents a clinically relevant experience that addresses national educational mandates regarding interdisciplinary care and chronic illness across care settings. We are now expanding the curriculum from the original site to our other clerkship sites and are evaluating its impact on patient safety and clinical outcomes. Future research should focus on whether these interdisciplinary postdischarge patient visits lead to improved attitudes and skills during residency training or practice and whether, ultimately, they lead to improved patient outcomes.

The increasing burden of chronic illness has prompted concerns about the traditional education model that focuses on management of acute disease.13 Chronic illness has replaced acute disease as the major cause of disability and total national health care expenditures.46 Medical educators have called for improved chronic disease curricula,2, 3 and the Institute of Medicine has asserted that health professions, including medicine and pharmacy, must reexamine how students are educated to manage patients with complex illnesses.7, 8 Despite the rising prevalence of chronic illness, the positive attitudes of medical students toward providing care to such patients decline during training.2, 9 One theory is that the current model of core clerkship training excessively exposes students to highly complex, seriously ill hospitalized patients. Students may become disillusioned and overwhelmed by these encounters, particularly without the opportunity to see improvement or thriving in the outpatient setting.2

There are few curricula on how to transition chronically ill patients from an inpatient to an outpatient setting and the inherent safety risks of this transition. For these patients, the posthospital discharge period is particularly confusing because of the sudden change in health status and new medication regimens.1012 It is very likely that communication among providers and patients will be insufficient during the discharge process,11, 1315 yet physicians tend to overestimate patients' understanding of postdischarge treatment plans and thereby underanticipate problems.16 One intervention to address these concerns is a postdischarge visit. Home visits have been shown to improve students' understanding of continuity of care and of the impact of chronic illness on their patients' medical and psychosocial situations.1719

There is scant structured teaching of third‐year medical students about another critical aspect of transitional care: the role of different health care disciplines. Although research about the impact of undergraduate interdisciplinary education on patient outcomes is limited, training students in interdisciplinary collaboration may improve their ability to provide quality care.2022 Multiple disciplines are critical for a smooth transition of chronically ill patients from an inpatient to an outpatient setting. In particular, pharmacist involvement in a predischarge medication review, patient counseling, and telephone follow‐up has been associated with improved outcomes.11, 12, 23, 24 Early introduction of interdisciplinary team training can improve student attitudes about working within a team.25

To teach the importance of safe discharges and interdisciplinary collaboration in caring for chronically ill patients, we developed an inpatient medicine clerkship curriculum for medical and pharmacy students that included postdischarge visits to students' own team patients. The purpose of the study was to assess the impact of this didactic and experiential curriculum on students' attitudes and self‐assessed skills in the interdisciplinary care and transitional care of chronically ill patients. We hypothesized that the discharge curriculum would improve student attitudes and self‐assessed skills in these domains. Finally, we hypothesized that visiting a patient's home would highlight for students the potential challenges of care transitions for patients.

METHODS

Intervention (Curriculum Description)

We developed a 3‐part pilot interdisciplinary curriculum (Fig. 1). During the first 2 weeks of the IM clerkship, interdisciplinary faculty, including 3 pharmacists, 2 hospitalists, and occasionally a social worker and geriatric clinical nurse specialist, led a 1‐hour interactive workshop on transitional care. The 3 workshop topics were: roles that various disciplines such as social work and pharmacy play in discharge care; the challenges a patient faces around the time of discharge, using a typical case; and discussion of elements of a postdischarge visit.

Figure 1

Medical and pharmacy students were partnered based on clerkship team assignments in teams of up to 3 student partners (1 or 2 medical students and 1 pharmacy student). Partners were advised to select a consenting patient known to them from the ward team for 1 postdischarge visit. Suggested selection criteria were at least 1 chronic illness, 1 prior hospitalization, and older than age 65 because patients fitting these criteria are most at risk for readmission or adverse outcomes following discharge.15, 26, 27 The student partners scheduled a postdischarge visit by the end of the rotation to the patient's home, nursing home, or subacute care facility. Each patient and the patient's primary care provider (PCP) gave informed consent.

During the postdischarge visit, student partners assessed medication discrepancies, environmental safety, and clinical status using structured data collection protocols developed by the investigators after review of the literature.28, 29 After the visit, students reported back to the ward teams on the patient's status and wrote a visit summary letter to the patient's PCP. The letter described the patient's clinical status and home environment, any medication discrepancies, and follow‐up plans and included a reflection piece. Reflection questions included, How did the visit change your perspective of patient discharge? What were the most critical aspects of this or any discharge? How do you think this experience will affect your future practice? What was the best thing about this experience?

During the last 2 weeks of the rotation, all student participants met with faculty preceptors for an hour‐long group debriefing session on the postdischarge visits.

RESULTS

DISCUSSION

A discharge curriculum that included a postdischarge visit to a recently hospitalized patient improved the attitudes and self‐assessed skills of third‐year medical students and fourth‐year pharmacy students about interdisciplinary collaboration and transitions in care. It also deepened their appreciation of the impact of chronic illness on individual patients. To our knowledge, this is the first study to report an interdisciplinary curriculum with postdischarge home visits for students on their inpatient medicine clerkship.

Our curriculum was unique because its activities were linked to patients the students had cared for in the inpatient setting, a relationship that was key to students accepting the curriculum, as was the autonomy they had in selecting one of their patients for a visit. Although home visits are often part of medical school training, they generally occur in the preclinical years5, 19 or during third‐year primary care rotations, during which students are assigned patients at home or in outpatient facilities.17, 32 Home visits have been qualitatively reported to be a valuable aspect of geriatric, primary care, and other ambulatory‐based rotations of medical students.17, 19, 32 Postdischarge visits in graduate medical education have been shown to improve residents' awareness of and skills with transitions in care.28, 33, 34

Another novel aspect of this curriculum was the interdisciplinary collaboration in discharge planning and postdischarge visits. Although educators have implemented conferences on interdisciplinary education in preclinical medical education,3537 patient‐centered curricula in real‐time allow realistic interdisciplinary collaboration between medical and pharmacy students in their core clerkships. In our study, quantitative and qualitative data showed that the student partners valued each other's expertise in the context of a clinically relevant activitydischarge planning and a follow‐up home visit. Students reported confidence in their collaborative abilities after completing the curriculum, and comments supported a broadened understanding of other professionals' roles in patient care. Given that pharmacist involvement in discharge planning has been shown to improve patient outcomes,11, 24 our study supports the idea that medical educators should develop structured curricula on interdisciplinary training in core clerkships.

By evaluating the impact of hospitalization and chronic illness on their patients after discharge, our students developed an appreciation for safe transitions and opportunities to improve patients' health and level of function. We observed that students also appreciated the positive effect of the home environment on patient health and well‐being. From their postdischarge visit, students also became aware of the need for communication with primary care providers, particularly for patients with comorbidities. This type of transitional care experience may help to counter the negative attitudes toward chronic illness that students typically develop during clerkships.2, 9, 38, 39

Of note, although pharmacy students reported improvement in their attitudes and skills with transitional care, the trend toward significance was less than that for medical students. This difference was consistent with the broader rotation goals of each group. At the end of the curriculum, the pharmacy students expressed more comfort with medication review than did medical students, although the latter were better able to conduct transitional care including postdischarge visits and identification of barriers or facilitators to a safe discharge. Another interesting note is that pharmacy students came into the curriculum with a better understanding of the roles of physicians, whereas the medical students had a less clear idea of the pharmacist's role. A possible explanation is that pharmacy students are better trained in their preclinical years to work as a team with medical personnel. The pharmacy school curriculum places an emphasis on independent learning and interdisciplinary collaboration, which may lead to the greater comfort felt by the pharmacy students.

This study had several limitations. The absolute number of visits was small overall; however, nearly all student partners completed their visits. Although the response rate to the postcurriculum survey was high, the response rate to matched prepost surveys was lower. In addition, the survey questions were not validated. Further, although there was significant improvement in students' attitudes and self‐assessed skills after completion of the curriculum, we cannot be certain whether this improvement was a result of the curriculum or of other rotation experiences. We attempted to clarify this effect by asking if the curriculum added to their learning beyond other clerkship experiences, and students perceived that our curriculum was responsible for the positive effect. Also, the curriculum was used at 1 academic site and may not be generalizable to other hospitals, student populations, or team structures. The patients were selected by students, and thus the results may not be reproducible for every population; in some situations, students had to ask several patients until a patient consented to a postdischarge visit.

In implementing this interdisciplinary curriculum, we were challenged by the discordant schedules of the medical and pharmacy students. Initially, it was also difficult to overcome students' concerns about adding an additional expectation to an already busy rotation. The medical students, in particular, voiced concerns about having to leave the hospital during their inpatient rotation. However, this has become much less of an issue with time as the value of the postdischarge visit has become clear to students and team members, with the latter now aware of and supportive of the program.

This discharge curriculum represents a clinically relevant experience that addresses national educational mandates regarding interdisciplinary care and chronic illness across care settings. We are now expanding the curriculum from the original site to our other clerkship sites and are evaluating its impact on patient safety and clinical outcomes. Future research should focus on whether these interdisciplinary postdischarge patient visits lead to improved attitudes and skills during residency training or practice and whether, ultimately, they lead to improved patient outcomes.

The increasing burden of chronic illness has prompted concerns about the traditional education model that focuses on management of acute disease.13 Chronic illness has replaced acute disease as the major cause of disability and total national health care expenditures.46 Medical educators have called for improved chronic disease curricula,2, 3 and the Institute of Medicine has asserted that health professions, including medicine and pharmacy, must reexamine how students are educated to manage patients with complex illnesses.7, 8 Despite the rising prevalence of chronic illness, the positive attitudes of medical students toward providing care to such patients decline during training.2, 9 One theory is that the current model of core clerkship training excessively exposes students to highly complex, seriously ill hospitalized patients. Students may become disillusioned and overwhelmed by these encounters, particularly without the opportunity to see improvement or thriving in the outpatient setting.2

There are few curricula on how to transition chronically ill patients from an inpatient to an outpatient setting and the inherent safety risks of this transition. For these patients, the posthospital discharge period is particularly confusing because of the sudden change in health status and new medication regimens.1012 It is very likely that communication among providers and patients will be insufficient during the discharge process,11, 1315 yet physicians tend to overestimate patients' understanding of postdischarge treatment plans and thereby underanticipate problems.16 One intervention to address these concerns is a postdischarge visit. Home visits have been shown to improve students' understanding of continuity of care and of the impact of chronic illness on their patients' medical and psychosocial situations.1719

There is scant structured teaching of third‐year medical students about another critical aspect of transitional care: the role of different health care disciplines. Although research about the impact of undergraduate interdisciplinary education on patient outcomes is limited, training students in interdisciplinary collaboration may improve their ability to provide quality care.2022 Multiple disciplines are critical for a smooth transition of chronically ill patients from an inpatient to an outpatient setting. In particular, pharmacist involvement in a predischarge medication review, patient counseling, and telephone follow‐up has been associated with improved outcomes.11, 12, 23, 24 Early introduction of interdisciplinary team training can improve student attitudes about working within a team.25

To teach the importance of safe discharges and interdisciplinary collaboration in caring for chronically ill patients, we developed an inpatient medicine clerkship curriculum for medical and pharmacy students that included postdischarge visits to students' own team patients. The purpose of the study was to assess the impact of this didactic and experiential curriculum on students' attitudes and self‐assessed skills in the interdisciplinary care and transitional care of chronically ill patients. We hypothesized that the discharge curriculum would improve student attitudes and self‐assessed skills in these domains. Finally, we hypothesized that visiting a patient's home would highlight for students the potential challenges of care transitions for patients.

METHODS

Intervention (Curriculum Description)

We developed a 3‐part pilot interdisciplinary curriculum (Fig. 1). During the first 2 weeks of the IM clerkship, interdisciplinary faculty, including 3 pharmacists, 2 hospitalists, and occasionally a social worker and geriatric clinical nurse specialist, led a 1‐hour interactive workshop on transitional care. The 3 workshop topics were: roles that various disciplines such as social work and pharmacy play in discharge care; the challenges a patient faces around the time of discharge, using a typical case; and discussion of elements of a postdischarge visit.

Figure 1

Medical and pharmacy students were partnered based on clerkship team assignments in teams of up to 3 student partners (1 or 2 medical students and 1 pharmacy student). Partners were advised to select a consenting patient known to them from the ward team for 1 postdischarge visit. Suggested selection criteria were at least 1 chronic illness, 1 prior hospitalization, and older than age 65 because patients fitting these criteria are most at risk for readmission or adverse outcomes following discharge.15, 26, 27 The student partners scheduled a postdischarge visit by the end of the rotation to the patient's home, nursing home, or subacute care facility. Each patient and the patient's primary care provider (PCP) gave informed consent.

During the postdischarge visit, student partners assessed medication discrepancies, environmental safety, and clinical status using structured data collection protocols developed by the investigators after review of the literature.28, 29 After the visit, students reported back to the ward teams on the patient's status and wrote a visit summary letter to the patient's PCP. The letter described the patient's clinical status and home environment, any medication discrepancies, and follow‐up plans and included a reflection piece. Reflection questions included, How did the visit change your perspective of patient discharge? What were the most critical aspects of this or any discharge? How do you think this experience will affect your future practice? What was the best thing about this experience?

During the last 2 weeks of the rotation, all student participants met with faculty preceptors for an hour‐long group debriefing session on the postdischarge visits.

RESULTS

DISCUSSION

A discharge curriculum that included a postdischarge visit to a recently hospitalized patient improved the attitudes and self‐assessed skills of third‐year medical students and fourth‐year pharmacy students about interdisciplinary collaboration and transitions in care. It also deepened their appreciation of the impact of chronic illness on individual patients. To our knowledge, this is the first study to report an interdisciplinary curriculum with postdischarge home visits for students on their inpatient medicine clerkship.

Our curriculum was unique because its activities were linked to patients the students had cared for in the inpatient setting, a relationship that was key to students accepting the curriculum, as was the autonomy they had in selecting one of their patients for a visit. Although home visits are often part of medical school training, they generally occur in the preclinical years5, 19 or during third‐year primary care rotations, during which students are assigned patients at home or in outpatient facilities.17, 32 Home visits have been qualitatively reported to be a valuable aspect of geriatric, primary care, and other ambulatory‐based rotations of medical students.17, 19, 32 Postdischarge visits in graduate medical education have been shown to improve residents' awareness of and skills with transitions in care.28, 33, 34

Another novel aspect of this curriculum was the interdisciplinary collaboration in discharge planning and postdischarge visits. Although educators have implemented conferences on interdisciplinary education in preclinical medical education,3537 patient‐centered curricula in real‐time allow realistic interdisciplinary collaboration between medical and pharmacy students in their core clerkships. In our study, quantitative and qualitative data showed that the student partners valued each other's expertise in the context of a clinically relevant activitydischarge planning and a follow‐up home visit. Students reported confidence in their collaborative abilities after completing the curriculum, and comments supported a broadened understanding of other professionals' roles in patient care. Given that pharmacist involvement in discharge planning has been shown to improve patient outcomes,11, 24 our study supports the idea that medical educators should develop structured curricula on interdisciplinary training in core clerkships.

By evaluating the impact of hospitalization and chronic illness on their patients after discharge, our students developed an appreciation for safe transitions and opportunities to improve patients' health and level of function. We observed that students also appreciated the positive effect of the home environment on patient health and well‐being. From their postdischarge visit, students also became aware of the need for communication with primary care providers, particularly for patients with comorbidities. This type of transitional care experience may help to counter the negative attitudes toward chronic illness that students typically develop during clerkships.2, 9, 38, 39

Of note, although pharmacy students reported improvement in their attitudes and skills with transitional care, the trend toward significance was less than that for medical students. This difference was consistent with the broader rotation goals of each group. At the end of the curriculum, the pharmacy students expressed more comfort with medication review than did medical students, although the latter were better able to conduct transitional care including postdischarge visits and identification of barriers or facilitators to a safe discharge. Another interesting note is that pharmacy students came into the curriculum with a better understanding of the roles of physicians, whereas the medical students had a less clear idea of the pharmacist's role. A possible explanation is that pharmacy students are better trained in their preclinical years to work as a team with medical personnel. The pharmacy school curriculum places an emphasis on independent learning and interdisciplinary collaboration, which may lead to the greater comfort felt by the pharmacy students.

This study had several limitations. The absolute number of visits was small overall; however, nearly all student partners completed their visits. Although the response rate to the postcurriculum survey was high, the response rate to matched prepost surveys was lower. In addition, the survey questions were not validated. Further, although there was significant improvement in students' attitudes and self‐assessed skills after completion of the curriculum, we cannot be certain whether this improvement was a result of the curriculum or of other rotation experiences. We attempted to clarify this effect by asking if the curriculum added to their learning beyond other clerkship experiences, and students perceived that our curriculum was responsible for the positive effect. Also, the curriculum was used at 1 academic site and may not be generalizable to other hospitals, student populations, or team structures. The patients were selected by students, and thus the results may not be reproducible for every population; in some situations, students had to ask several patients until a patient consented to a postdischarge visit.

In implementing this interdisciplinary curriculum, we were challenged by the discordant schedules of the medical and pharmacy students. Initially, it was also difficult to overcome students' concerns about adding an additional expectation to an already busy rotation. The medical students, in particular, voiced concerns about having to leave the hospital during their inpatient rotation. However, this has become much less of an issue with time as the value of the postdischarge visit has become clear to students and team members, with the latter now aware of and supportive of the program.

This discharge curriculum represents a clinically relevant experience that addresses national educational mandates regarding interdisciplinary care and chronic illness across care settings. We are now expanding the curriculum from the original site to our other clerkship sites and are evaluating its impact on patient safety and clinical outcomes. Future research should focus on whether these interdisciplinary postdischarge patient visits lead to improved attitudes and skills during residency training or practice and whether, ultimately, they lead to improved patient outcomes.

A 72‐year‐old man had been suffering from low‐grade fever, minimally productive cough, and shortness of breath for 1 week when he experienced sudden, moderately severe right‐sided chest pain. His local primary care physician found no abnormalities on physical exam and laboratory testing. A chest x‐ray, however, did reveal a small right‐sided pleural effusion. The patient was empirically started on levofloxacin but noticed no improvement. Two weeks into his illness, he was referred to our institution for further management. By this time, he reported a rapid 10‐pound weight loss and a daily low‐grade fever. Chest examination revealed dullness to percussion along with decreased breath sounds in the right posterior lung fields. A complete blood count showed an elevated white count of 17,000/mL with 14,000 neutrophils. Hemoglobin was 13.5 g/dL. A repeat chest x‐ ray and then a CT scan showed a multiloculated pleural effusion in the right lower hemithorax. Ultrasound‐guided tap of this effusion showed cloudy fluid consistent with pus, with a protein of 4.8 g/dL and total nucleated cells of 6000/mL. A gram stain on this fluid was negative.

The patient had a history remarkable for severe underlying chronic obstructive pulmonary disease (COPD). His forced expiratory volume in 1 second (FEV1) was 21%, and his diffusing capacity of carbon monoxide (DLCO) was 27%. Therefore, decortication under general anesthesia was not an option. So the largest pus pocket was drained under CT guidance, and the patient was dismissed home on levofloxacin.

He returned for follow‐up after 3 weeks and reported daily low‐grade fever, night sweats, and an additional weight loss of 14 pounds. His white count had risen to 18,300/mL with a neutrophil count of 16,600. Hemoglobin had fallen to 11.9 g/dL. A repeat CT scan showed that although the previously drained fluid pocket had resolved, a moderate amount of fluid had reaccumulated in other pockets. Delayed anaerobic culture results from the hospitalization 3 weeks earlier were now available and, interestingly, showed 2+ growth of Campylobacter jejuni, broadly sensitive to all antibiotics including penicillin. Piperacillin/tazobactam was started intravenously, and CT‐guided drainage of the largest pus pocket was again performed.

We carefully reexamined the patient's CT scan, and there appeared to be a lesion in the right main‐stem bronchus. We decided to perform a bronchoscopy, which revealed a foreign body in the right main‐stem bronchus. The foreign body turned out to be a piece of chicken and a peanut. On specific questioning of the patient again, he admitted that at times he coughed after eating too quickly. Specifically, he remembered that a few days before falling sick he was at a village fair, where he had had chicken, and he thought he might have coughed after eating it. He denied any diarrheal illness in the recent past. We obtained a swallow study and upper gastrointestinal endoscopy, both of which were unremarkable.

He improved remarkably after removal of the foreign body and was sent home on amoxicillin‐clavulanic acid for 3 weeks.

DISCUSSION

Campylobacter is one of the most common zoonoses in the world.1 Commercially raised poultry is nearly always colonized with Campylobacter jejuni, and therefore, not surprisingly, 50% to 70% of C. jejuni infection in humans is caused by undercooked poultry.2 The most common presentation of C. jejuni in humans is acute enteritis or colitis, but it can have numerous extraintestinal manifestations.3 Bacteremia occurs in fewer than 1% of patients, but C. jejuni meningitis and endocarditis have been reported. Hepatitis, interstitial nephritis, hemolytic‐uremic syndrome, and IgA nephropathy are other reported complications. Our patient probably aspirated a piece of undercooked chicken that likely was the source of the C. jejuni, causing a persistent empyema.

Most patients fully recover from C. jejuni infections without medications, but if illness is severe or prolonged, antibiotics are recommended. Macrolides are usually the first‐line treatment, but their increasing veterinary use is leading to their being resistant to these drugs.4 Most isolates are not susceptible to cephalosporins or penicillins, except amoxicillin or ticarcillin plus clavulanic acid. The C. jejuni isolated in culture in our lab from this patient was unusual in being broadly sensitive.

Our patient aspirated a foreign body in the form of chicken and a peanut without even realizing it. This is extremely uncommon, although foreign‐body aspiration in otherwise healthy and alert adults sometimes does occur. The most common presentation is sudden choking, coughing, and vomiting, followed by wheezing and breathlessness. Patients may also present with persistent cough, hemoptysis, fever, breathlessness, or wheezing. Children may present with cyanosis.

Inorganic foreign bodies tend to be from dental accidents, and organic aspirated foreign bodies tend to depend on the types of food eaten in a particular population, with bones, nuts, and apple pips the most common. In adults, all foreign bodies tend to lodge in the right bronchial tree. Aspiration of organic material is usually diagnosed later than aspiration of nonorganic material.5 In either case, airway foreign‐body aspiration is a common cause of recurrent bacterial pneumonia, and long delays in diagnosis are quite typical.6

Plain x‐rays may be entirely normal. A CT may demonstrate an aspirated foreign body in the lumen of the tracheobronchial tree. Other common findings are atelectasis, hyperlucency, bronchiectasis, lobar consolidation, ipsilateral pleural effusion, and lymphadenopathy and a thickened bronchial wall adjacent to the foreign body.7 Newer methods such as CT virtual bronchoscopy are being evaluated for use in selected cases when clinical suspicion is high.8 0

Figure 1

A 72‐year‐old man had been suffering from low‐grade fever, minimally productive cough, and shortness of breath for 1 week when he experienced sudden, moderately severe right‐sided chest pain. His local primary care physician found no abnormalities on physical exam and laboratory testing. A chest x‐ray, however, did reveal a small right‐sided pleural effusion. The patient was empirically started on levofloxacin but noticed no improvement. Two weeks into his illness, he was referred to our institution for further management. By this time, he reported a rapid 10‐pound weight loss and a daily low‐grade fever. Chest examination revealed dullness to percussion along with decreased breath sounds in the right posterior lung fields. A complete blood count showed an elevated white count of 17,000/mL with 14,000 neutrophils. Hemoglobin was 13.5 g/dL. A repeat chest x‐ ray and then a CT scan showed a multiloculated pleural effusion in the right lower hemithorax. Ultrasound‐guided tap of this effusion showed cloudy fluid consistent with pus, with a protein of 4.8 g/dL and total nucleated cells of 6000/mL. A gram stain on this fluid was negative.

The patient had a history remarkable for severe underlying chronic obstructive pulmonary disease (COPD). His forced expiratory volume in 1 second (FEV1) was 21%, and his diffusing capacity of carbon monoxide (DLCO) was 27%. Therefore, decortication under general anesthesia was not an option. So the largest pus pocket was drained under CT guidance, and the patient was dismissed home on levofloxacin.

He returned for follow‐up after 3 weeks and reported daily low‐grade fever, night sweats, and an additional weight loss of 14 pounds. His white count had risen to 18,300/mL with a neutrophil count of 16,600. Hemoglobin had fallen to 11.9 g/dL. A repeat CT scan showed that although the previously drained fluid pocket had resolved, a moderate amount of fluid had reaccumulated in other pockets. Delayed anaerobic culture results from the hospitalization 3 weeks earlier were now available and, interestingly, showed 2+ growth of Campylobacter jejuni, broadly sensitive to all antibiotics including penicillin. Piperacillin/tazobactam was started intravenously, and CT‐guided drainage of the largest pus pocket was again performed.

We carefully reexamined the patient's CT scan, and there appeared to be a lesion in the right main‐stem bronchus. We decided to perform a bronchoscopy, which revealed a foreign body in the right main‐stem bronchus. The foreign body turned out to be a piece of chicken and a peanut. On specific questioning of the patient again, he admitted that at times he coughed after eating too quickly. Specifically, he remembered that a few days before falling sick he was at a village fair, where he had had chicken, and he thought he might have coughed after eating it. He denied any diarrheal illness in the recent past. We obtained a swallow study and upper gastrointestinal endoscopy, both of which were unremarkable.

He improved remarkably after removal of the foreign body and was sent home on amoxicillin‐clavulanic acid for 3 weeks.

DISCUSSION

Campylobacter is one of the most common zoonoses in the world.1 Commercially raised poultry is nearly always colonized with Campylobacter jejuni, and therefore, not surprisingly, 50% to 70% of C. jejuni infection in humans is caused by undercooked poultry.2 The most common presentation of C. jejuni in humans is acute enteritis or colitis, but it can have numerous extraintestinal manifestations.3 Bacteremia occurs in fewer than 1% of patients, but C. jejuni meningitis and endocarditis have been reported. Hepatitis, interstitial nephritis, hemolytic‐uremic syndrome, and IgA nephropathy are other reported complications. Our patient probably aspirated a piece of undercooked chicken that likely was the source of the C. jejuni, causing a persistent empyema.

Most patients fully recover from C. jejuni infections without medications, but if illness is severe or prolonged, antibiotics are recommended. Macrolides are usually the first‐line treatment, but their increasing veterinary use is leading to their being resistant to these drugs.4 Most isolates are not susceptible to cephalosporins or penicillins, except amoxicillin or ticarcillin plus clavulanic acid. The C. jejuni isolated in culture in our lab from this patient was unusual in being broadly sensitive.

Our patient aspirated a foreign body in the form of chicken and a peanut without even realizing it. This is extremely uncommon, although foreign‐body aspiration in otherwise healthy and alert adults sometimes does occur. The most common presentation is sudden choking, coughing, and vomiting, followed by wheezing and breathlessness. Patients may also present with persistent cough, hemoptysis, fever, breathlessness, or wheezing. Children may present with cyanosis.

Inorganic foreign bodies tend to be from dental accidents, and organic aspirated foreign bodies tend to depend on the types of food eaten in a particular population, with bones, nuts, and apple pips the most common. In adults, all foreign bodies tend to lodge in the right bronchial tree. Aspiration of organic material is usually diagnosed later than aspiration of nonorganic material.5 In either case, airway foreign‐body aspiration is a common cause of recurrent bacterial pneumonia, and long delays in diagnosis are quite typical.6

Plain x‐rays may be entirely normal. A CT may demonstrate an aspirated foreign body in the lumen of the tracheobronchial tree. Other common findings are atelectasis, hyperlucency, bronchiectasis, lobar consolidation, ipsilateral pleural effusion, and lymphadenopathy and a thickened bronchial wall adjacent to the foreign body.7 Newer methods such as CT virtual bronchoscopy are being evaluated for use in selected cases when clinical suspicion is high.8 0

Figure 1

A 72‐year‐old man had been suffering from low‐grade fever, minimally productive cough, and shortness of breath for 1 week when he experienced sudden, moderately severe right‐sided chest pain. His local primary care physician found no abnormalities on physical exam and laboratory testing. A chest x‐ray, however, did reveal a small right‐sided pleural effusion. The patient was empirically started on levofloxacin but noticed no improvement. Two weeks into his illness, he was referred to our institution for further management. By this time, he reported a rapid 10‐pound weight loss and a daily low‐grade fever. Chest examination revealed dullness to percussion along with decreased breath sounds in the right posterior lung fields. A complete blood count showed an elevated white count of 17,000/mL with 14,000 neutrophils. Hemoglobin was 13.5 g/dL. A repeat chest x‐ ray and then a CT scan showed a multiloculated pleural effusion in the right lower hemithorax. Ultrasound‐guided tap of this effusion showed cloudy fluid consistent with pus, with a protein of 4.8 g/dL and total nucleated cells of 6000/mL. A gram stain on this fluid was negative.

The patient had a history remarkable for severe underlying chronic obstructive pulmonary disease (COPD). His forced expiratory volume in 1 second (FEV1) was 21%, and his diffusing capacity of carbon monoxide (DLCO) was 27%. Therefore, decortication under general anesthesia was not an option. So the largest pus pocket was drained under CT guidance, and the patient was dismissed home on levofloxacin.

He returned for follow‐up after 3 weeks and reported daily low‐grade fever, night sweats, and an additional weight loss of 14 pounds. His white count had risen to 18,300/mL with a neutrophil count of 16,600. Hemoglobin had fallen to 11.9 g/dL. A repeat CT scan showed that although the previously drained fluid pocket had resolved, a moderate amount of fluid had reaccumulated in other pockets. Delayed anaerobic culture results from the hospitalization 3 weeks earlier were now available and, interestingly, showed 2+ growth of Campylobacter jejuni, broadly sensitive to all antibiotics including penicillin. Piperacillin/tazobactam was started intravenously, and CT‐guided drainage of the largest pus pocket was again performed.

We carefully reexamined the patient's CT scan, and there appeared to be a lesion in the right main‐stem bronchus. We decided to perform a bronchoscopy, which revealed a foreign body in the right main‐stem bronchus. The foreign body turned out to be a piece of chicken and a peanut. On specific questioning of the patient again, he admitted that at times he coughed after eating too quickly. Specifically, he remembered that a few days before falling sick he was at a village fair, where he had had chicken, and he thought he might have coughed after eating it. He denied any diarrheal illness in the recent past. We obtained a swallow study and upper gastrointestinal endoscopy, both of which were unremarkable.

He improved remarkably after removal of the foreign body and was sent home on amoxicillin‐clavulanic acid for 3 weeks.

DISCUSSION

Campylobacter is one of the most common zoonoses in the world.1 Commercially raised poultry is nearly always colonized with Campylobacter jejuni, and therefore, not surprisingly, 50% to 70% of C. jejuni infection in humans is caused by undercooked poultry.2 The most common presentation of C. jejuni in humans is acute enteritis or colitis, but it can have numerous extraintestinal manifestations.3 Bacteremia occurs in fewer than 1% of patients, but C. jejuni meningitis and endocarditis have been reported. Hepatitis, interstitial nephritis, hemolytic‐uremic syndrome, and IgA nephropathy are other reported complications. Our patient probably aspirated a piece of undercooked chicken that likely was the source of the C. jejuni, causing a persistent empyema.

Most patients fully recover from C. jejuni infections without medications, but if illness is severe or prolonged, antibiotics are recommended. Macrolides are usually the first‐line treatment, but their increasing veterinary use is leading to their being resistant to these drugs.4 Most isolates are not susceptible to cephalosporins or penicillins, except amoxicillin or ticarcillin plus clavulanic acid. The C. jejuni isolated in culture in our lab from this patient was unusual in being broadly sensitive.

Our patient aspirated a foreign body in the form of chicken and a peanut without even realizing it. This is extremely uncommon, although foreign‐body aspiration in otherwise healthy and alert adults sometimes does occur. The most common presentation is sudden choking, coughing, and vomiting, followed by wheezing and breathlessness. Patients may also present with persistent cough, hemoptysis, fever, breathlessness, or wheezing. Children may present with cyanosis.

Inorganic foreign bodies tend to be from dental accidents, and organic aspirated foreign bodies tend to depend on the types of food eaten in a particular population, with bones, nuts, and apple pips the most common. In adults, all foreign bodies tend to lodge in the right bronchial tree. Aspiration of organic material is usually diagnosed later than aspiration of nonorganic material.5 In either case, airway foreign‐body aspiration is a common cause of recurrent bacterial pneumonia, and long delays in diagnosis are quite typical.6

Plain x‐rays may be entirely normal. A CT may demonstrate an aspirated foreign body in the lumen of the tracheobronchial tree. Other common findings are atelectasis, hyperlucency, bronchiectasis, lobar consolidation, ipsilateral pleural effusion, and lymphadenopathy and a thickened bronchial wall adjacent to the foreign body.7 Newer methods such as CT virtual bronchoscopy are being evaluated for use in selected cases when clinical suspicion is high.8 0

Figure 1

Autonomy is one of the most familiar principles in Western bioethics, whereas informed consent is probably its most practical expression.1 Autonomy's modern formulation was particularly shaped by political philosophers like John Locke (1632‐1704), who worried about the coercive powers of the state.2 As Lockean‐inspired governments evolved over the last 3 centuries, their legislatures became increasingly disposed to granting citizens an ever‐increasing number of individual rights and freedoms. In American medicine, that sensibility began to take a determinate shape early in the 20th century, such as in Judge Benjamin Cardozo's famous declaration in 1914 that:

Another half century would be required, however, to agree on the informational content, or scope of disclosure, that would reasonably educate patients on what they would be consenting to. Precedent‐setting decisions in the 1960s and 1970s, such as in Natanson v. Kline4 and Canterbury v. Spence,5 ultimately held that informing a patient about a proposed clinical intervention must include an explanation as to why the intervention is recommended and what particular benefits might accrue from it. Most important, however, is informing the patient about any significant risks the intervention poses. Not associated with or pertaining to error or negligence, but rather understood as foreseeable complications or adverse events that could occur even if the standard of care was scrupulously followed, risk information must be imparted to decisionally able patients or their surrogates to honor their autonomy, or right of bodily ownership.6

The problem with determining whether a risk should be disclosed is that it is often reduced to a judgment call about a risk's severity and frequency. The common understanding is that risks whose severity and frequency are both extremely low need not be discussed. Risk disclosure becomes complex when either of these variables begins to increase, but even then, a significant likelihood of temporary headache or gastrointestinal upset associated with some treatment might not be mentioned. On the other hand, courts have awarded damages to plaintiffs who experienced the materialization of a 1 in 2500 chance of a serious but undisclosed risk.7 The ethical challenge in judging whether a particular risk needs to be disclosed involves the difficulty inherent in determining at what point in the comingling of risk severity and likelihood of materialization does disclosure become required.8

The article by Upadhyay et al. investigates a related facet about risk disclosure.9 For a long time, hospitals have exhibited inconsistent policies for securing informed consent for certain common but nevertheless risky procedures or treatments, especially those involving medications. Many hospitals, for example, would have staff members simply tell patients that they needed diuretics or thrombolytics, even though in certain instances, and especially with thrombolytic agents, the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%).8

The article by Upadhyay et al. suggests at least 3 issues meriting serious ethical consideration. The first is that the risk scenario primarily discussed in the articlea serious cerebral bleed from thrombolysis with a frequency of from 1% to 20%would most certainly require formal informed consent from patients. To the extent that hospitals recognize such risk scenarios but fail to secure informed consent, they are violating their patients' autonomous rights. The article by Upadhyay et al. is therefore a clarion call to these institutions to become more aggressive and conscientious in honoring their informed consent duties to patients.

A second issue is that the patients surveyed in the study overwhelmingly desired risk disclosure. Notice that if a treatment's risk magnitude is such that it would normally obligate disclosure, the only factors that would preclude disclosure in nonemergent cases would be (1) if the patient was deemed judgmentally or psychologically impaired (and even then, next of kin or the patient's proxy would need to be contacted and informed) or (2) if the patient refused to hear a recitation of the risks (perhaps because it would cause him or her excessive anxiety).10 Otherwise, and as implied by the empirical findings reported in the article, disclosure in an instance like thrombolysis would not only be consistent with (and therefore obligated by) more familiar instances of disclosure such as occur in surgical interventions, it would also be consistent with patient centeredness, as indicated by the responses of the research participants themselves.

But a third issue raises a serious ethical complication. Many patients interviewed in this study also wanted informed consent (or at least wanted to provide permission) for seemingly banal medical interventions. Although respecting patient autonomy is an enduring tenet of medical ethics, it can be argued that it could be limited by other ethical constraints. If respecting a patient's autonomy becomes synonymous with an ethical obligation to disclose all potential risks of every possible treatment regardless of their likelihood or severity, the physician's time might be unreasonably compromised.11 For example, it seems fair to say that many physicians would think it ethically excessive or unreasonable to demand that busy hospitalists discuss the risks, benefits, alternatives, and likelihood of success before ordering intravenous furosemide, potassium supplementation, or routine phlebotomy.

In the general care of hospitalized patients, virtually all physicians will obtain specific, written informed consent prior to invasive procedures, but many might assume that consent for routine medical care has been secured during the consent documentation process of the patient's admission to hospital. Upadhyay et al.'s findings, however, make us question the extent to which consent on admission is ethically sufficient. If it is not, then we must ask what other opportunities exist for effecting patient‐centered explanations of proposed interventions without unduly compromising a health professional's duties and commitments during the workday.

A solution may consist in the way that artful communication skills are key to the physicianpatient relationship. The Accreditation Council on Graduate Medical Education outlines 6 core competencies that all resident physicians should attain during training. One core measure is communication skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.12

Perhaps the individuals surveyed in this study would not require explicit informed consent from a physician if they enjoyed an appropriate number of informational exchanges with all their treating professionals. Their daily treatment plan with its attendant risks and benefits could be discussed in reasonable detail, their comprehension could be elicited through teach back, and their remaining concerns could be explored through empathic communication techniques. This process, which would fold informed consent into a more elaborate, transparent, and humanistically oriented sharing of information, might ease the tension over autonomy versus time constraints by spreading informational responsibilities throughout the health care system. Achieving that quality of informational exchange, however, will require a serious institutional and especially educational commitment in our undergraduate and graduate training programs because it is unlikely that most physicians or other health professionals would seek such skill development on their own.

Autonomy is one of the most familiar principles in Western bioethics, whereas informed consent is probably its most practical expression.1 Autonomy's modern formulation was particularly shaped by political philosophers like John Locke (1632‐1704), who worried about the coercive powers of the state.2 As Lockean‐inspired governments evolved over the last 3 centuries, their legislatures became increasingly disposed to granting citizens an ever‐increasing number of individual rights and freedoms. In American medicine, that sensibility began to take a determinate shape early in the 20th century, such as in Judge Benjamin Cardozo's famous declaration in 1914 that:

Another half century would be required, however, to agree on the informational content, or scope of disclosure, that would reasonably educate patients on what they would be consenting to. Precedent‐setting decisions in the 1960s and 1970s, such as in Natanson v. Kline4 and Canterbury v. Spence,5 ultimately held that informing a patient about a proposed clinical intervention must include an explanation as to why the intervention is recommended and what particular benefits might accrue from it. Most important, however, is informing the patient about any significant risks the intervention poses. Not associated with or pertaining to error or negligence, but rather understood as foreseeable complications or adverse events that could occur even if the standard of care was scrupulously followed, risk information must be imparted to decisionally able patients or their surrogates to honor their autonomy, or right of bodily ownership.6

The problem with determining whether a risk should be disclosed is that it is often reduced to a judgment call about a risk's severity and frequency. The common understanding is that risks whose severity and frequency are both extremely low need not be discussed. Risk disclosure becomes complex when either of these variables begins to increase, but even then, a significant likelihood of temporary headache or gastrointestinal upset associated with some treatment might not be mentioned. On the other hand, courts have awarded damages to plaintiffs who experienced the materialization of a 1 in 2500 chance of a serious but undisclosed risk.7 The ethical challenge in judging whether a particular risk needs to be disclosed involves the difficulty inherent in determining at what point in the comingling of risk severity and likelihood of materialization does disclosure become required.8

The article by Upadhyay et al. investigates a related facet about risk disclosure.9 For a long time, hospitals have exhibited inconsistent policies for securing informed consent for certain common but nevertheless risky procedures or treatments, especially those involving medications. Many hospitals, for example, would have staff members simply tell patients that they needed diuretics or thrombolytics, even though in certain instances, and especially with thrombolytic agents, the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%).8

The article by Upadhyay et al. suggests at least 3 issues meriting serious ethical consideration. The first is that the risk scenario primarily discussed in the articlea serious cerebral bleed from thrombolysis with a frequency of from 1% to 20%would most certainly require formal informed consent from patients. To the extent that hospitals recognize such risk scenarios but fail to secure informed consent, they are violating their patients' autonomous rights. The article by Upadhyay et al. is therefore a clarion call to these institutions to become more aggressive and conscientious in honoring their informed consent duties to patients.

A second issue is that the patients surveyed in the study overwhelmingly desired risk disclosure. Notice that if a treatment's risk magnitude is such that it would normally obligate disclosure, the only factors that would preclude disclosure in nonemergent cases would be (1) if the patient was deemed judgmentally or psychologically impaired (and even then, next of kin or the patient's proxy would need to be contacted and informed) or (2) if the patient refused to hear a recitation of the risks (perhaps because it would cause him or her excessive anxiety).10 Otherwise, and as implied by the empirical findings reported in the article, disclosure in an instance like thrombolysis would not only be consistent with (and therefore obligated by) more familiar instances of disclosure such as occur in surgical interventions, it would also be consistent with patient centeredness, as indicated by the responses of the research participants themselves.

But a third issue raises a serious ethical complication. Many patients interviewed in this study also wanted informed consent (or at least wanted to provide permission) for seemingly banal medical interventions. Although respecting patient autonomy is an enduring tenet of medical ethics, it can be argued that it could be limited by other ethical constraints. If respecting a patient's autonomy becomes synonymous with an ethical obligation to disclose all potential risks of every possible treatment regardless of their likelihood or severity, the physician's time might be unreasonably compromised.11 For example, it seems fair to say that many physicians would think it ethically excessive or unreasonable to demand that busy hospitalists discuss the risks, benefits, alternatives, and likelihood of success before ordering intravenous furosemide, potassium supplementation, or routine phlebotomy.

In the general care of hospitalized patients, virtually all physicians will obtain specific, written informed consent prior to invasive procedures, but many might assume that consent for routine medical care has been secured during the consent documentation process of the patient's admission to hospital. Upadhyay et al.'s findings, however, make us question the extent to which consent on admission is ethically sufficient. If it is not, then we must ask what other opportunities exist for effecting patient‐centered explanations of proposed interventions without unduly compromising a health professional's duties and commitments during the workday.

A solution may consist in the way that artful communication skills are key to the physicianpatient relationship. The Accreditation Council on Graduate Medical Education outlines 6 core competencies that all resident physicians should attain during training. One core measure is communication skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.12

Perhaps the individuals surveyed in this study would not require explicit informed consent from a physician if they enjoyed an appropriate number of informational exchanges with all their treating professionals. Their daily treatment plan with its attendant risks and benefits could be discussed in reasonable detail, their comprehension could be elicited through teach back, and their remaining concerns could be explored through empathic communication techniques. This process, which would fold informed consent into a more elaborate, transparent, and humanistically oriented sharing of information, might ease the tension over autonomy versus time constraints by spreading informational responsibilities throughout the health care system. Achieving that quality of informational exchange, however, will require a serious institutional and especially educational commitment in our undergraduate and graduate training programs because it is unlikely that most physicians or other health professionals would seek such skill development on their own.

Autonomy is one of the most familiar principles in Western bioethics, whereas informed consent is probably its most practical expression.1 Autonomy's modern formulation was particularly shaped by political philosophers like John Locke (1632‐1704), who worried about the coercive powers of the state.2 As Lockean‐inspired governments evolved over the last 3 centuries, their legislatures became increasingly disposed to granting citizens an ever‐increasing number of individual rights and freedoms. In American medicine, that sensibility began to take a determinate shape early in the 20th century, such as in Judge Benjamin Cardozo's famous declaration in 1914 that:

Another half century would be required, however, to agree on the informational content, or scope of disclosure, that would reasonably educate patients on what they would be consenting to. Precedent‐setting decisions in the 1960s and 1970s, such as in Natanson v. Kline4 and Canterbury v. Spence,5 ultimately held that informing a patient about a proposed clinical intervention must include an explanation as to why the intervention is recommended and what particular benefits might accrue from it. Most important, however, is informing the patient about any significant risks the intervention poses. Not associated with or pertaining to error or negligence, but rather understood as foreseeable complications or adverse events that could occur even if the standard of care was scrupulously followed, risk information must be imparted to decisionally able patients or their surrogates to honor their autonomy, or right of bodily ownership.6

The problem with determining whether a risk should be disclosed is that it is often reduced to a judgment call about a risk's severity and frequency. The common understanding is that risks whose severity and frequency are both extremely low need not be discussed. Risk disclosure becomes complex when either of these variables begins to increase, but even then, a significant likelihood of temporary headache or gastrointestinal upset associated with some treatment might not be mentioned. On the other hand, courts have awarded damages to plaintiffs who experienced the materialization of a 1 in 2500 chance of a serious but undisclosed risk.7 The ethical challenge in judging whether a particular risk needs to be disclosed involves the difficulty inherent in determining at what point in the comingling of risk severity and likelihood of materialization does disclosure become required.8

The article by Upadhyay et al. investigates a related facet about risk disclosure.9 For a long time, hospitals have exhibited inconsistent policies for securing informed consent for certain common but nevertheless risky procedures or treatments, especially those involving medications. Many hospitals, for example, would have staff members simply tell patients that they needed diuretics or thrombolytics, even though in certain instances, and especially with thrombolytic agents, the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%).8

The article by Upadhyay et al. suggests at least 3 issues meriting serious ethical consideration. The first is that the risk scenario primarily discussed in the articlea serious cerebral bleed from thrombolysis with a frequency of from 1% to 20%would most certainly require formal informed consent from patients. To the extent that hospitals recognize such risk scenarios but fail to secure informed consent, they are violating their patients' autonomous rights. The article by Upadhyay et al. is therefore a clarion call to these institutions to become more aggressive and conscientious in honoring their informed consent duties to patients.

A second issue is that the patients surveyed in the study overwhelmingly desired risk disclosure. Notice that if a treatment's risk magnitude is such that it would normally obligate disclosure, the only factors that would preclude disclosure in nonemergent cases would be (1) if the patient was deemed judgmentally or psychologically impaired (and even then, next of kin or the patient's proxy would need to be contacted and informed) or (2) if the patient refused to hear a recitation of the risks (perhaps because it would cause him or her excessive anxiety).10 Otherwise, and as implied by the empirical findings reported in the article, disclosure in an instance like thrombolysis would not only be consistent with (and therefore obligated by) more familiar instances of disclosure such as occur in surgical interventions, it would also be consistent with patient centeredness, as indicated by the responses of the research participants themselves.

But a third issue raises a serious ethical complication. Many patients interviewed in this study also wanted informed consent (or at least wanted to provide permission) for seemingly banal medical interventions. Although respecting patient autonomy is an enduring tenet of medical ethics, it can be argued that it could be limited by other ethical constraints. If respecting a patient's autonomy becomes synonymous with an ethical obligation to disclose all potential risks of every possible treatment regardless of their likelihood or severity, the physician's time might be unreasonably compromised.11 For example, it seems fair to say that many physicians would think it ethically excessive or unreasonable to demand that busy hospitalists discuss the risks, benefits, alternatives, and likelihood of success before ordering intravenous furosemide, potassium supplementation, or routine phlebotomy.

In the general care of hospitalized patients, virtually all physicians will obtain specific, written informed consent prior to invasive procedures, but many might assume that consent for routine medical care has been secured during the consent documentation process of the patient's admission to hospital. Upadhyay et al.'s findings, however, make us question the extent to which consent on admission is ethically sufficient. If it is not, then we must ask what other opportunities exist for effecting patient‐centered explanations of proposed interventions without unduly compromising a health professional's duties and commitments during the workday.

A solution may consist in the way that artful communication skills are key to the physicianpatient relationship. The Accreditation Council on Graduate Medical Education outlines 6 core competencies that all resident physicians should attain during training. One core measure is communication skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates.12

Perhaps the individuals surveyed in this study would not require explicit informed consent from a physician if they enjoyed an appropriate number of informational exchanges with all their treating professionals. Their daily treatment plan with its attendant risks and benefits could be discussed in reasonable detail, their comprehension could be elicited through teach back, and their remaining concerns could be explored through empathic communication techniques. This process, which would fold informed consent into a more elaborate, transparent, and humanistically oriented sharing of information, might ease the tension over autonomy versus time constraints by spreading informational responsibilities throughout the health care system. Achieving that quality of informational exchange, however, will require a serious institutional and especially educational commitment in our undergraduate and graduate training programs because it is unlikely that most physicians or other health professionals would seek such skill development on their own.

The period immediately following hospital discharge is a vulnerable time for patients, who must assume responsibilities for their own care as they return home.1 The process of hospital discharge may be a rushed event, and patients often have difficulty understanding and following their postdischarge treatment plan.2, 3 Medication‐related problems after hospital discharge, which include patients not filling or refilling prescriptions,46 not understanding how to take medications,2, 3 showing discrepancies between what they are and what they should be taking,79 and having adverse drug events,1012 are a major cause of morbidity and mortality.13

According to prior studies, elderly patients and patients taking more than 5 medications are more likely to experience problems with their medications.5, 14 Adverse drug events are more common with certain high‐risk drugs, including cardiovascular agents, anticoagulants, insulin, antibiotics, and steroids.11, 14, 15 Beyond this, however, patient management of prescription medications after hospital discharge has not been well described. In particular, studies in the community setting and in the immediate postdischarge period are needed.

We conducted a large observational study of patients at 170 community hospitals in order to examine the frequency of prescription‐related issues 4872 hours after hospital discharge. These issues included problems with filling or taking medications prescribed at discharge. We hypothesized that age and number of medications would be independently associated with prescription‐related problems. We also examined the effects of other factors, including insurance type, length of stay, severity of illness (SOI), clinical diagnosis, and use of certain high‐risk drugs.

METHODS

RESULTS

In 2005, there were 104,506 eligible adult hospital discharges, corresponding to 96,179 patients. Excluding discharged patients who could not be contacted by the call center or who refused to complete the survey (n = 67,084), multiple surveys of the same patient (n = 3156), and surveys with insufficient data to determine whether there were prescription‐related issues (n = 3067) left 31,199 patients available for analysis (effective response rate 32.4%).

More than half the participants (57.0%) were women, and the mean age was 61.1 years (SD 17.8 years). The median number of discharge medications was 4 (range 128). The most frequently prescribed drugs were antibiotics and analgesics, followed by several cardiovascular drug classes (Table 1). About 60% of the primary diagnoses were of circulatory, digestive, and respiratory disorders (Table 1). Compared with nonparticipants, the study sample was more likely to be female, older, and covered by Medicare. Study patients also had greater comorbidity, as indicated by greater severity of illness rating and number of discharge medications.

Overall, 7.2% of patients (n = 2253) had prescription‐related issues 4872 hours after hospital discharge. This included not picking up prescribed discharge medications (n = 1797, or 79.8% of issues), not knowing if they were picked up (n = 55 or 2.4%), and admitting to not taking (n = 154, or 6.8%) or not understanding how to take (n = 247, or 11%) medications.

In unadjusted analyses, prescription‐related issues were significantly associated with age, sex, insurance type, severity of illness rating, length of stay, number of discharge medications, certain medication types, and major diagnostic category (Table 2). Except for the youngest patients (age < 35 years), having prescription‐related issues appeared to be inversely related to patient age. Adults 3549 years old had the highest frequency of problems filling or taking medications (9.3%), whereas patients 80 years or older had the lowest frequency (5.6%). Analysis by insurance status showed that patients with Medicaid (12.6%) or self‐pay/uninsured status (11.9%) had significantly higher rates of prescription issues and patients with non‐Medicare HMO or commercial insurance had significantly lower rates (6.1% and 4.9%, respectively). Being prescribed at least 6 medications or taking ACE inhibitors, inhalers, oral hypoglycemics, or insulins was also associated with a higher frequency of prescription‐related problems in unadjusted analyses. Patients prescribed antibiotics or anticoagulants were less likely to report problems in unadjusted analyses.

In multivariable models, age, sex, insurance type, severity of illness, number of medications, and certain medication types were independently associated with prescription‐related issues after discharge (Table 3). Seniors reported significantly fewer problems than the youngest patients (6579 years, OR 0.69; 80 years, OR 0.59). Those with Medicare HMOs, Medicaid, or no insurance had more difficulty obtaining and taking prescription medications (OR 1.29, 1.33, and 1.31, respectively), whereas patients with HMO or commercial insurance plans had less difficulty (OR 0.68 and 0.51, respectively). Prescription‐related problems were also more common among women (OR 1.11), patients with higher severity of illness (moderate SOI, OR 1.12; major/extreme SOI, OR 1.23), and those with 6 or more discharge medications (OR 1.35). In adjusted analyses, inhalers were the only type of medication associated with a significantly higher frequency of problems (OR 1.14).

Analyses were repeated using only failure to pick up medications as the dependent variable, and results were similar (not shown).

DISCUSSION

In this large multicenter study, 7.2% of patients reported problems obtaining or taking prescribed medications in the 4872 hours following hospital discharge. In about 80% of cases, the problem was failure to pick up discharge medications. Multivariable analyses showed adults 3549 years old; women; patients with Medicare HMO insurance, Medicaid, or no coverage (self‐pay); adults with high severity of illness rating; and those prescribed more than 5 medications or an inhaler had significantly greater odds of prescription‐related issues. Other factors were protective including age 65 or older; HMO or commercial insurance; prescription of antibiotics, anticoagulants, or angiotensin II receptor blockers; and major diagnosis in the skin or musculoskeletal category.

Among all the groups studied, patients with Medicaid or no insurance had the highest frequency of problems filling and taking discharge medications (12.6% and 11.9%, respectively). This was likely related to their having less prescription drug coverage or experiencing other financial constraints. In previous studies, patients have expressed concern over the rising cost of medications and have admitted to not filling prescriptions or stretching out the use of medications to make them last longer because of high out‐of‐pocket costs.5, 16 Prescriptions given at hospital discharge may pose a significant unexpected expense for patients who have a fixed monthly income, rely on samples from outpatient physicians for their medications, or need time to research cost‐saving measures such as discount plans. Greater attention by physicians to knowing the cost of discharge medications, to prescribing only those drugs that are truly necessary, and to discussing cost‐saving strategies with patients may help to minimize financial concerns and improve the ability of patients to fill discharge prescriptions.17

The finding that polypharmacy is associated with greater odds of prescription‐related issues is consistent with research that found that other medication problems such as adverse drug events and nonadherence were more prevalent among patients prescribed more than 5 medications.5, 14 Polypharmacy may have contributed to prescription‐related difficulties in this study by increasing medication costs or by increasing the chance that patients had a problem with at least 1 medication.

The higher frequency of prescription‐related issues among patients prescribed inhalers indicates that this category of medication may be associated with lower fill rates or greater confusion after discharge. This would be concerning, given that repeat exacerbations of obstructive lung disease may lead to rehospitalization. Other medications, including anticoagulants and antibiotics, were associated with a lower frequency of problems. This may have been the result of better education at discharge about the importance of promptly filling prescriptions for these agents in order to avoid a lapse in therapy following acute treatment for thromboembolic disorders or acute infections. It is hoped that a similar educational effort about filling prescriptions for inhalers also would have occurred. These effects have not been noted in prior research and require further substantiation.11, 14 Also, the observed relationships may be related to the size of the data set and the number of variables considered, rather than to a true effect.

The main strength of this study was that the data from which conclusions were drawn came from a large and geographically diverse patient population. However, the study also had several limitations. First, the response rate was relatively low, primarily because this study was a retrospective analysis performed using data collected for clinical and administrative reasons. Patient contact number was missing or incorrect in 16% of cases. Also, because of the narrow window of time during which the survey was administered, the call center, which was following up an average of 370 discharged patients per day, was only able to make 1 or 2 attempts to reach each patient. This contrasts with prospective research on postdischarge medication use such as the study by Forster and colleagues, in which the investigator made up to 20 attempts to reach patients at different times and on different days.11 Despite these efforts, the follow‐up rate was only 69%, underscoring the challenge of data collection in this setting.

The low response rate raises the possibility that the estimated prevalence of prescription‐related issues may be inaccurate. Although highly unlikely, if all the nonresponders had problems with their prescriptions, the true event rate would be 69.9%. Conversely, if none of the nonresponders had problems, the true event rate would be 2.3%. Given the characteristics of responders and nonresponders, however, we expect that a higher survey completion rate would have yielded similar results. Nonresponders had certain characteristics that would be expected to be associated with a higher frequency of prescription‐related issues (younger age, uninsured, covered by Medicaid), but these were balanced by others that would be expected to be associated with a lower frequency of problems (higher percentage of men, lower severity of illness, fewer medications).

Another study limitation concerns the self‐reported nature of the composite outcome variable. After reviewing the structure of the call center data, we chose this composite measure because it conceptually represented difficulties in obtaining or taking prescribed discharge medications. When we analyzed results using only the most prevalent component of this composite variable, the results were similar. However, all these findings could have been influenced by social desirability bias. Patients may have underreported not filling their discharge prescriptions and also may not acknowledged difficulties in understanding how to take the medications. We would therefore expect the true prevalence of prescription‐related concerns after hospital discharge to be higher than that found in this study.

These limitations notwithstanding, the findings from this large, multicenter study show that prescription‐related issues are common after hospital discharge and, further, that they usually take the form of not filling discharge prescriptions. The highest‐risk patients appear to be those without insurance and those covered by Medicaid or Medicare HMOs, as well as adults age 3549, patients prescribed 6 or more medications, and patients with a higher severity of illness. When preparing patients to leave the hospital, physicians and other health care providers should strive to identify financial, behavioral, and other barriers to proper medication use so that appropriate assistance or counseling may be offered prior to discharge.18, 19 Close follow‐up of patients by telephone may also be a helpful approach to promptly identifying prescription‐related issues and other problems so that providers can intervene before more serious complications arise.

The period immediately following hospital discharge is a vulnerable time for patients, who must assume responsibilities for their own care as they return home.1 The process of hospital discharge may be a rushed event, and patients often have difficulty understanding and following their postdischarge treatment plan.2, 3 Medication‐related problems after hospital discharge, which include patients not filling or refilling prescriptions,46 not understanding how to take medications,2, 3 showing discrepancies between what they are and what they should be taking,79 and having adverse drug events,1012 are a major cause of morbidity and mortality.13

According to prior studies, elderly patients and patients taking more than 5 medications are more likely to experience problems with their medications.5, 14 Adverse drug events are more common with certain high‐risk drugs, including cardiovascular agents, anticoagulants, insulin, antibiotics, and steroids.11, 14, 15 Beyond this, however, patient management of prescription medications after hospital discharge has not been well described. In particular, studies in the community setting and in the immediate postdischarge period are needed.

We conducted a large observational study of patients at 170 community hospitals in order to examine the frequency of prescription‐related issues 4872 hours after hospital discharge. These issues included problems with filling or taking medications prescribed at discharge. We hypothesized that age and number of medications would be independently associated with prescription‐related problems. We also examined the effects of other factors, including insurance type, length of stay, severity of illness (SOI), clinical diagnosis, and use of certain high‐risk drugs.

METHODS

RESULTS

In 2005, there were 104,506 eligible adult hospital discharges, corresponding to 96,179 patients. Excluding discharged patients who could not be contacted by the call center or who refused to complete the survey (n = 67,084), multiple surveys of the same patient (n = 3156), and surveys with insufficient data to determine whether there were prescription‐related issues (n = 3067) left 31,199 patients available for analysis (effective response rate 32.4%).

More than half the participants (57.0%) were women, and the mean age was 61.1 years (SD 17.8 years). The median number of discharge medications was 4 (range 128). The most frequently prescribed drugs were antibiotics and analgesics, followed by several cardiovascular drug classes (Table 1). About 60% of the primary diagnoses were of circulatory, digestive, and respiratory disorders (Table 1). Compared with nonparticipants, the study sample was more likely to be female, older, and covered by Medicare. Study patients also had greater comorbidity, as indicated by greater severity of illness rating and number of discharge medications.

Overall, 7.2% of patients (n = 2253) had prescription‐related issues 4872 hours after hospital discharge. This included not picking up prescribed discharge medications (n = 1797, or 79.8% of issues), not knowing if they were picked up (n = 55 or 2.4%), and admitting to not taking (n = 154, or 6.8%) or not understanding how to take (n = 247, or 11%) medications.

In unadjusted analyses, prescription‐related issues were significantly associated with age, sex, insurance type, severity of illness rating, length of stay, number of discharge medications, certain medication types, and major diagnostic category (Table 2). Except for the youngest patients (age < 35 years), having prescription‐related issues appeared to be inversely related to patient age. Adults 3549 years old had the highest frequency of problems filling or taking medications (9.3%), whereas patients 80 years or older had the lowest frequency (5.6%). Analysis by insurance status showed that patients with Medicaid (12.6%) or self‐pay/uninsured status (11.9%) had significantly higher rates of prescription issues and patients with non‐Medicare HMO or commercial insurance had significantly lower rates (6.1% and 4.9%, respectively). Being prescribed at least 6 medications or taking ACE inhibitors, inhalers, oral hypoglycemics, or insulins was also associated with a higher frequency of prescription‐related problems in unadjusted analyses. Patients prescribed antibiotics or anticoagulants were less likely to report problems in unadjusted analyses.

In multivariable models, age, sex, insurance type, severity of illness, number of medications, and certain medication types were independently associated with prescription‐related issues after discharge (Table 3). Seniors reported significantly fewer problems than the youngest patients (6579 years, OR 0.69; 80 years, OR 0.59). Those with Medicare HMOs, Medicaid, or no insurance had more difficulty obtaining and taking prescription medications (OR 1.29, 1.33, and 1.31, respectively), whereas patients with HMO or commercial insurance plans had less difficulty (OR 0.68 and 0.51, respectively). Prescription‐related problems were also more common among women (OR 1.11), patients with higher severity of illness (moderate SOI, OR 1.12; major/extreme SOI, OR 1.23), and those with 6 or more discharge medications (OR 1.35). In adjusted analyses, inhalers were the only type of medication associated with a significantly higher frequency of problems (OR 1.14).

Analyses were repeated using only failure to pick up medications as the dependent variable, and results were similar (not shown).

DISCUSSION

In this large multicenter study, 7.2% of patients reported problems obtaining or taking prescribed medications in the 4872 hours following hospital discharge. In about 80% of cases, the problem was failure to pick up discharge medications. Multivariable analyses showed adults 3549 years old; women; patients with Medicare HMO insurance, Medicaid, or no coverage (self‐pay); adults with high severity of illness rating; and those prescribed more than 5 medications or an inhaler had significantly greater odds of prescription‐related issues. Other factors were protective including age 65 or older; HMO or commercial insurance; prescription of antibiotics, anticoagulants, or angiotensin II receptor blockers; and major diagnosis in the skin or musculoskeletal category.

Among all the groups studied, patients with Medicaid or no insurance had the highest frequency of problems filling and taking discharge medications (12.6% and 11.9%, respectively). This was likely related to their having less prescription drug coverage or experiencing other financial constraints. In previous studies, patients have expressed concern over the rising cost of medications and have admitted to not filling prescriptions or stretching out the use of medications to make them last longer because of high out‐of‐pocket costs.5, 16 Prescriptions given at hospital discharge may pose a significant unexpected expense for patients who have a fixed monthly income, rely on samples from outpatient physicians for their medications, or need time to research cost‐saving measures such as discount plans. Greater attention by physicians to knowing the cost of discharge medications, to prescribing only those drugs that are truly necessary, and to discussing cost‐saving strategies with patients may help to minimize financial concerns and improve the ability of patients to fill discharge prescriptions.17

The finding that polypharmacy is associated with greater odds of prescription‐related issues is consistent with research that found that other medication problems such as adverse drug events and nonadherence were more prevalent among patients prescribed more than 5 medications.5, 14 Polypharmacy may have contributed to prescription‐related difficulties in this study by increasing medication costs or by increasing the chance that patients had a problem with at least 1 medication.

The higher frequency of prescription‐related issues among patients prescribed inhalers indicates that this category of medication may be associated with lower fill rates or greater confusion after discharge. This would be concerning, given that repeat exacerbations of obstructive lung disease may lead to rehospitalization. Other medications, including anticoagulants and antibiotics, were associated with a lower frequency of problems. This may have been the result of better education at discharge about the importance of promptly filling prescriptions for these agents in order to avoid a lapse in therapy following acute treatment for thromboembolic disorders or acute infections. It is hoped that a similar educational effort about filling prescriptions for inhalers also would have occurred. These effects have not been noted in prior research and require further substantiation.11, 14 Also, the observed relationships may be related to the size of the data set and the number of variables considered, rather than to a true effect.

The main strength of this study was that the data from which conclusions were drawn came from a large and geographically diverse patient population. However, the study also had several limitations. First, the response rate was relatively low, primarily because this study was a retrospective analysis performed using data collected for clinical and administrative reasons. Patient contact number was missing or incorrect in 16% of cases. Also, because of the narrow window of time during which the survey was administered, the call center, which was following up an average of 370 discharged patients per day, was only able to make 1 or 2 attempts to reach each patient. This contrasts with prospective research on postdischarge medication use such as the study by Forster and colleagues, in which the investigator made up to 20 attempts to reach patients at different times and on different days.11 Despite these efforts, the follow‐up rate was only 69%, underscoring the challenge of data collection in this setting.

The low response rate raises the possibility that the estimated prevalence of prescription‐related issues may be inaccurate. Although highly unlikely, if all the nonresponders had problems with their prescriptions, the true event rate would be 69.9%. Conversely, if none of the nonresponders had problems, the true event rate would be 2.3%. Given the characteristics of responders and nonresponders, however, we expect that a higher survey completion rate would have yielded similar results. Nonresponders had certain characteristics that would be expected to be associated with a higher frequency of prescription‐related issues (younger age, uninsured, covered by Medicaid), but these were balanced by others that would be expected to be associated with a lower frequency of problems (higher percentage of men, lower severity of illness, fewer medications).

Another study limitation concerns the self‐reported nature of the composite outcome variable. After reviewing the structure of the call center data, we chose this composite measure because it conceptually represented difficulties in obtaining or taking prescribed discharge medications. When we analyzed results using only the most prevalent component of this composite variable, the results were similar. However, all these findings could have been influenced by social desirability bias. Patients may have underreported not filling their discharge prescriptions and also may not acknowledged difficulties in understanding how to take the medications. We would therefore expect the true prevalence of prescription‐related concerns after hospital discharge to be higher than that found in this study.

These limitations notwithstanding, the findings from this large, multicenter study show that prescription‐related issues are common after hospital discharge and, further, that they usually take the form of not filling discharge prescriptions. The highest‐risk patients appear to be those without insurance and those covered by Medicaid or Medicare HMOs, as well as adults age 3549, patients prescribed 6 or more medications, and patients with a higher severity of illness. When preparing patients to leave the hospital, physicians and other health care providers should strive to identify financial, behavioral, and other barriers to proper medication use so that appropriate assistance or counseling may be offered prior to discharge.18, 19 Close follow‐up of patients by telephone may also be a helpful approach to promptly identifying prescription‐related issues and other problems so that providers can intervene before more serious complications arise.

The period immediately following hospital discharge is a vulnerable time for patients, who must assume responsibilities for their own care as they return home.1 The process of hospital discharge may be a rushed event, and patients often have difficulty understanding and following their postdischarge treatment plan.2, 3 Medication‐related problems after hospital discharge, which include patients not filling or refilling prescriptions,46 not understanding how to take medications,2, 3 showing discrepancies between what they are and what they should be taking,79 and having adverse drug events,1012 are a major cause of morbidity and mortality.13

According to prior studies, elderly patients and patients taking more than 5 medications are more likely to experience problems with their medications.5, 14 Adverse drug events are more common with certain high‐risk drugs, including cardiovascular agents, anticoagulants, insulin, antibiotics, and steroids.11, 14, 15 Beyond this, however, patient management of prescription medications after hospital discharge has not been well described. In particular, studies in the community setting and in the immediate postdischarge period are needed.

We conducted a large observational study of patients at 170 community hospitals in order to examine the frequency of prescription‐related issues 4872 hours after hospital discharge. These issues included problems with filling or taking medications prescribed at discharge. We hypothesized that age and number of medications would be independently associated with prescription‐related problems. We also examined the effects of other factors, including insurance type, length of stay, severity of illness (SOI), clinical diagnosis, and use of certain high‐risk drugs.

METHODS

RESULTS

In 2005, there were 104,506 eligible adult hospital discharges, corresponding to 96,179 patients. Excluding discharged patients who could not be contacted by the call center or who refused to complete the survey (n = 67,084), multiple surveys of the same patient (n = 3156), and surveys with insufficient data to determine whether there were prescription‐related issues (n = 3067) left 31,199 patients available for analysis (effective response rate 32.4%).

More than half the participants (57.0%) were women, and the mean age was 61.1 years (SD 17.8 years). The median number of discharge medications was 4 (range 128). The most frequently prescribed drugs were antibiotics and analgesics, followed by several cardiovascular drug classes (Table 1). About 60% of the primary diagnoses were of circulatory, digestive, and respiratory disorders (Table 1). Compared with nonparticipants, the study sample was more likely to be female, older, and covered by Medicare. Study patients also had greater comorbidity, as indicated by greater severity of illness rating and number of discharge medications.

Overall, 7.2% of patients (n = 2253) had prescription‐related issues 4872 hours after hospital discharge. This included not picking up prescribed discharge medications (n = 1797, or 79.8% of issues), not knowing if they were picked up (n = 55 or 2.4%), and admitting to not taking (n = 154, or 6.8%) or not understanding how to take (n = 247, or 11%) medications.

In unadjusted analyses, prescription‐related issues were significantly associated with age, sex, insurance type, severity of illness rating, length of stay, number of discharge medications, certain medication types, and major diagnostic category (Table 2). Except for the youngest patients (age < 35 years), having prescription‐related issues appeared to be inversely related to patient age. Adults 3549 years old had the highest frequency of problems filling or taking medications (9.3%), whereas patients 80 years or older had the lowest frequency (5.6%). Analysis by insurance status showed that patients with Medicaid (12.6%) or self‐pay/uninsured status (11.9%) had significantly higher rates of prescription issues and patients with non‐Medicare HMO or commercial insurance had significantly lower rates (6.1% and 4.9%, respectively). Being prescribed at least 6 medications or taking ACE inhibitors, inhalers, oral hypoglycemics, or insulins was also associated with a higher frequency of prescription‐related problems in unadjusted analyses. Patients prescribed antibiotics or anticoagulants were less likely to report problems in unadjusted analyses.